Provider Demographics
NPI:1063407906
Name:STEVENS, MARY S (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 COMMERCIAL LN
Mailing Address - Street 2:WTCSB
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8148
Mailing Address - Country:US
Mailing Address - Phone:757-942-1069
Mailing Address - Fax:757-925-2213
Practice Address - Street 1:1000 COMMERCIAL LN
Practice Address - Street 2:WTCSB
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8148
Practice Address - Country:US
Practice Address - Phone:757-942-1069
Practice Address - Fax:757-925-2213
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904002094101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8904766Medicaid
VAO83006OtherOPITMA FAMILY CARE
VA270371OtherTRIGONBC/BS HEALTHKEEPERS
VA8904766Medicaid